Toradol

[GaseousClay]

Do you inform the surgeon about giving toradol regardless of the surgery? I usually don't and I use discretion on when to use it but had a surgeon the other day say he was shocked that "you guys don't tell us if/when you are going to use toradol".

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[agammaglobulin]

I'm a resident so I ask before giving most times. If surgeon says no (almost always...) I ask them why and then I try to engage in a discussion about why not. Most of the time they don't change their minds, but I hope the next time they at least think about it before saying no. The only evidence against I'm aware of is in regard to renal dz, h/o ulcers, reduced dose in elderly, and long bone fractures. Any other times people don't use it?

 

[GaseousClay]

I also avoid bad asthmatics and if there was significant bleeding just so surgeon won't trip out. otherwise same as you. I just think its funny that they think we wouldn't know the indications and contraindications of an NSAID. They also tend to think 1 dose of it can actually cause more adverse surgical effects than it is capable of.

 

[pgg]

I do as I please, unless I've had a previous altercation with that particular surgeon over the issue. Them, I will either ask or just skip it.

But I start from the default position that it's OK for me to do the right thing without their input.

It's just not worth arguing with someone who thinks it'll cause a post-lap-chole liver bleed.

 

[G-Man82]

I usually don't ask. But then again I do so little outpatient stuff it doesn't really matter to me. But in residency I wouldn't ask unless my attending wanted me to ask. They were usually of the mindset that after PACU discharge it's the surgeon's problem anyway. Drove me nuts.

 

[gotname]

Do you inform the surgeon about giving toradol regardless of the surgery? I usually don't and I use discretion on when to use it but had a surgeon the other day say he was shocked that "you guys don't tell us if/when you are going to use toradol".

I'm a patient (sorry) but this just happened to me. Anaesthesiologist gave toradol without surgeon's knowledge...ended up admitted after bleeding (my platelets are useless).

My view was/is that the anaesthesiologist did do his job. However, the surgeon (has operated on me a #of times) knows me better and would have been able to provide insight as to why toradol use would be a bad idea in that situation.

Even if they were both new to me, I guess as a patient, I would hope that the two docs in charge of my wellbeing in the operating room are on the same page...

But then again, I have no clue about the kinds of politics you all have to deal with!

 

[Ignatius J]

I'm a patient (sorry) but this just happened to me. Anaesthesiologist gave toradol without surgeon's knowledge...ended up admitted after bleeding (my platelets are useless).

My view was/is that the anaesthesiologist did do his job. However, the surgeon (has operated on me a #of times) knows me better and would have been able to provide insight as to why toradol use would be a bad idea in that situation.

Even if they were both new to me, I guess as a patient, I would hope that the two docs in charge of my wellbeing in the operating room are on the same page...

But then again, I have no clue about the kinds of politics you all have to deal with!

There's actually significant data to disspell the notion that a single dose of Toradol causes bleeding. More than likely your surgeon had a surgical bleeding issue combined with your admittedly bad platelet profile and found a scapegoat.

Here you go:

http://journals.lww.com/plasreconsu...is_of_Postoperative_Bleeding_with_the.85.aspx

Please tell your surgeon to go apologize for his mistake if he blamed the anesthesiologist.

 

[2win]

Do you inform the surgeon about giving toradol regardless of the surgery? I usually don't and I use discretion on when to use it but had a surgeon the other day say he was shocked that "you guys don't tell us if/when you are going to use toradol".

I didn't read the others replies..
Short answer - choose your battle.
Really you can attain postop good results with narcotics IF you are not concerned about respiratory drive ( COPD) or narcotics will interfere with the neuro exam.
About the ortho complaints...oh well
EBM tell them to read before they open their mouth.
Real world and depending of your status there - let them to have their way.
I don't just because I can make them cry.
Lucky for me - they know me well.
2win

 

[agammaglobulin]

There's actually significant data to disspell the notion that a single dose of Toradol causes bleeding. More than likely your surgeon had a surgical bleeding issue combined with your admittedly bad platelet profile and found a scapegoat.

Here you go:

http://journals.lww.com/plasreconsu...is_of_Postoperative_Bleeding_with_the.85.aspx

Please tell your surgeon to go apologize for his mistake if he blamed the anesthesiologist.

Another article here. http://www.ncbi.nlm.nih.gov/pubmed/25647706

2300 patients, 27 study meta-analysis with Ketorolac dosing 7.5-60mg. Included microvascular, flaps, tonsillectomy, etc. 0 (ZERO!) studies showed significant increase intraop or post-op bleeding in ketorolac vs control.

 

[vector2]

What's the evidence re: postpartum bleeding with toradol and csections?

 

[2win]

Another article here. http://www.ncbi.nlm.nih.gov/pubmed/25647706

2300 patients, 27 study meta-analysis with Ketorolac dosing 7.5-60mg. Included microvascular, flaps, tonsillectomy, etc. 0 (ZERO!) studies showed significant increase intraop or post-op bleeding in ketorolac vs control.

Here we go!
Data,
on the other side I would"t waste my breath arguing too much about that.
2win

 

[IlDestriero]

I ask as I don't want them to blame me for their surgical bleeding problem like they did with the poster above.
If a little Toradol caused significant bleeding, we wouldn't use it in OB for the c/s cases, which we do (30mg q6 x4).
They are not elegant surgeons, things are always oozing, they don't care and the women all do fine. If a (cough) hack (cough) OB surgeon can slash away and give 4 does of Toradol with no problems, the other surgeons don't have anything to worry about.
But, I ask anyway.

 

[Mman]

15 mg of ketorolac doesn't cause bleeding. I don't tell them if I give it, although in select patients/surgeries I will choose to avoid giving it. I'm 0 for forever in having a patient need to come back for postop bleeding from it.

 

[epidural man]

It's pretty clear it causes increased bleeding in tonsillectomy - other than that - doesn't increase bleeding.

Don't ask - my vote.

Do you ask if you give dexamethasone for nausea and vomiting - there is clear data in the harm caused by too much of this drug. What about 5-HT3 inhibitors? Case reports of horrible cardiac problems with these drugs....

If you use vasopressin post induction on a patient using an ACE-I - ask about this? This has been shown to worsen acid-base status in some circumstances - perhaps ask if you should give this?

I'm not sure why anesthesiologist have drawn a line at ketorolac, and nothing else - seems strange to me.

 

[gotname]

There's actually significant data to disspell the notion that a single dose of Toradol causes bleeding. More than likely your surgeon had a surgical bleeding issue combined with your admittedly bad platelet profile and found a scapegoat.

Here you go:

http://journals.lww.com/plasreconsu...is_of_Postoperative_Bleeding_with_the.85.aspx

Please tell your surgeon to go apologize for his mistake if he blamed the anesthesiologist.

Thanks for the article. Informative. Will share with my surgeon.

The blame came in because I had informed anaesthesiologist during preop interview that my docs (surgeon included) keep me off NSAIDs (I bleed very easily). He said what I read here - one dose should be ok. Bad luck on my part, I guess. But everything worked out in the end.

 

[PainDrain]

I feel that a single dose of toradol is highly unlikely to cause significant bleeding in the vast majority of patients. I never tell the surgeon. Remember the majority of bleeding post-op is poor surgical technique, ie silk deficiency. That being said there are certain folks I don't use it in and anyone over 70 I typically double check their renal function and PLT count, just to cover my butt. Considering the ever increasing size of the average American I feel that if a dose of toradol (and IV Tylenol added in the mix) spares some opiate use post-op that is great and far less likely to kill them than the 10mg of morphine in the patient with undiagnosed OSA.

 

[deleted126335]

There is decent evidence that it causes bleeding in tonsillectomies. If true, logically, it may cause bleeding in other procedures.
The surgeon is going to have to deal with post op pain, renal issues, bleeding - whatever the cause of the bleeding or renal failure, etc. They want their patients to do well and be satisfied and pain free. So I have no problem deferring to their personal preference on this issue. If I have a patient who I think would benefit more than usual, e.g., chronic narcotics, low pain tolerance, I will ask that they reconsider their personal preference on this issue for that patient.

 

[loveumms]

I have a discussion because we are mutually taking care of the patient. If I have to give significant vasopressors, I also alert the surgeon. It's their patient too. My job is to optimize conditions for them and keep the patient safe, not keep a secret of what I'm doing.

There is now some evidence that toradol causes anastomotic problems in GI procedures. Most of our surgeons are requesting we not give it for those surgeries.

 

[Ignatius J]

There is decent evidence that it causes bleeding in tonsillectomies. If true, logically, it may cause bleeding in other procedures.
The surgeon is going to have to deal with post op pain, renal issues, bleeding - whatever the cause of the bleeding or renal failure, etc. They want their patients to do well and be satisfied and pain free. So I have no problem deferring to their personal preference on this issue. If I have a patient who I think would benefit more than usual, e.g., chronic narcotics, low pain tolerance, I will ask that they reconsider their personal preference on this issue for that patient.

There are both studies for and against it in tonsillectomies. Of note, many of the studies have the toradol dosed at 1mg/kg (which is a hefty dose) and were done at a time when cold steel was used more commonly. I think you can't overlook the u/s bovie and harmonic scalpel and all that jazz that has become the standard of care to use these days in procedures. It ain't just slicing and dicing anymore.

A recent meta-analysis shows that it is okay in pedi tonsillectomies but increases bleeding in adults. The meta-analysis spans a lot of years. I would be interested to see what a recent dosing trial of 30mg given at extubation does. Maybe someone can find a recent prospective study with that.

One friend of mine (co-resident) gave Toradol to herself after her tonsillectomy as her pain was quite severe and she thanked the stars in the heavens for it. Said it put the hydrocodone to shame.

 

[Ignatius J]

http://www.ncbi.nlm.nih.gov/pubmed/9698951

 

[Ignatius J]

I have a discussion because we are mutually taking care of the patient. If I have to give significant vasopressors, I also alert the surgeon. It's their patient too. My job is to optimize conditions for them and keep the patient safe, not keep a secret of what I'm doing.

There is now some evidence that toradol causes anastomotic problems in GI procedures. Most of our surgeons are requesting we not give it for those surgeries.

I treat it like any other medication I give. I don't tell him that I'm giving Zofran, fentanyl, morphine, paralytic, etc. either. If I truly thought it could have a detrimental effect, I would say so. But the data says that it doesn't cause bleeding anymore (only exception is debate of tonsillectomies) than vaccines cause autism.

 

[Laryngophed]

So what about in ortho procedures?

 

[leaverus]

I'm a patient (sorry) but this just happened to me. Anaesthesiologist gave toradol without surgeon's knowledge...ended up admitted after bleeding (my platelets are useless).

My view was/is that the anaesthesiologist did do his job. However, the surgeon (has operated on me a #of times) knows me better and would have been able to provide insight as to why toradol use would be a bad idea in that situation.

why does the surgeon know you better because he's operated on you before? did the anesthesiologist not do a pre-operative assessment? usually, things like "useless platelets" are disclosed at that time. and why are you using the british spelling of anesthesiologist?

 

[agammaglobulin]

.

 

[gotname]

why does the surgeon know you better because he's operated on you before? did the anesthesiologist not do a pre-operative assessment? usually, things like "useless platelets" are disclosed at that time. and why are you using the british spelling of anesthesiologist?

He knows me better = he is familiar with my medical history from seeing me and has communicated with my regular physicians enough to have a good picture of overall health from their perspectives as well.

Anaesthesiologist did do a preop assessment and I did mention that my docs have me steer clear of NSAIDs and of course, the useless platelets and recent count (90, which was in the chart). He said one dose will be fine.

I did not notice (British spelling) until you asked. It's how I was taught...some things have stuck U.K version, most have not.

 

[agammaglobulin]

I have a discussion because we are mutually taking care of the patient. If I have to give significant vasopressors, I also alert the surgeon. It's their patient too. My job is to optimize conditions for them and keep the patient safe, not keep a secret of what I'm doing.

There is now some evidence that toradol causes anastomotic problems in GI procedures. Most of our surgeons are requesting we not give it for those surgeries.

Re GI anastomotic procedures:

http://www.ncbi.nlm.nih.gov/pubmed/25607250

New article from WA state's surgical care and outcomes assessment program (SCOAP). Retrospective Cohort, 13,000 patients, NSAIDs started within 24 hrs after surgery. Excerpt from article 'We found an association of NSAIDs and anastomotic complications ISOLATED TO PATIENTS UNDERGOING NONELECTIVE colorectal surgery. These procedures likely take place in the settings of infection, inflammation and hemodynamic instability or shock'

 

[PainDrain]

Re GI anastomotic procedures:

http://www.ncbi.nlm.nih.gov/pubmed/25607250

New article from WA state's surgical care and outcomes assessment program (SCOAP). Retrospective Cohort, 13,000 patients, NSAIDs started within 24 hrs after surgery. Excerpt from article 'We found an association of NSAIDs and anastomotic complications ISOLATED TO PATIENTS UNDERGOING NONELECTIVE colorectal surgery. These procedures likely take place in the settings of infection, inflammation and hemodynamic instability or shock'

So the Devils in the details.

 

[Mman]

also with any study on toradol, the dose is important. I never give more than 15 mg to an adult. There is plenty of evidence you can get equal pain control down to 5 mg or 10 mg, but I don't find the need to go that low.

 

[Planktonmd]

If a patient says "I don't want you to use this medication", regardless of what reason they state and regardless of what my personal opinion might be, I just don't use that medication and I don't even try to argue or convince them unless that medication is absolutely necessary for their care.

 

[Ignatius J]

If a patient says "I don't want you to use this medication", regardless of what reason they state and regardless of what my personal opinion might be, I just don't use that medication and I don't even try to argue or convince them unless that medication is absolutely necessary for their care.

Not sure where this is relevant here.

 

[Twiggidy]

Honestly, and it's just me, I try to avoid it at least until they're well in recovery. I dodge it in my renal peeps (although my vascular surgeon who is very picky about what his renal patients get asked me to give Toradol. I figured if it's ok with him then it's ok with me.) I usually give preop 1 G tylenol and if they're hurting in Recovery then go with some Toradol. I do the same for C/S. I did have a stretch of oozers in C/S's who got toradol after the baby was delivered so I changed to Tylenol and haven't had a case since. Clearly no a concrete study, but my own voodoo works for me. They can then start Toradol 3 hrs after. I feel it distances me from the blame of bleeding.

Pick battles, because in anesthesia, you're mostly likely to lose them all.

 

[Twiggidy]

If a patient says "I don't want you to use this medication", regardless of what reason they state and regardless of what my personal opinion might be, I just don't use that medication and I don't even try to argue or convince them unless that medication is absolutely necessary for their care.

Like the people who list propofol as their allergy and give some garbage reason. I with you. I don't argue with people anymore. I just go about my business and live to see another day.

 

[Planktonmd]

Not sure where this is relevant here.

Anaesthesiologist did do a preop assessment and I did mention that my docs have me steer clear of NSAIDs and of course, the useless platelets and recent count (90, which was in the chart). He said one dose will be fine.

If you read the thread (assuming you can read) you could have figured out what I meant!

 

[Ignatius J]

Anaesthesiologist did do a preop assessment and I did mention that my docs have me steer clear of NSAIDs and of course, the useless platelets and recent count (90, which was in the chart). He said one dose will be fine.

If you read the thread (assuming you can read) you could have figured out what I meant!

Big difference in a patient relaying information from her physicians and stating that she doesn't want you to give it. Patients relay information all the time from their physicians that I don't agree with. Doesn't mean I do what their physicians say. That's not fair to the patient or myself.

 

[pgg]

Patients say all kinds of crazy things. I step lightly around crazy people, and of course wouldn't give a crazy person a drug he thinks he's allergic too. Except epinephrine, I'd still use that.

When surgeons say crazy things, well ...


Agree that 15 mg is enough for many patients.

 

[Planktonmd]

Big difference in a patient relaying information from her physicians and stating that she doesn't want you to give it. Patients relay information all the time from their physicians that I don't agree with. Doesn't mean I do what their physicians say. That's not fair to the patient or myself.

You will become less idealistic when you start working under your own license

 

[gotname]

Big difference in a patient relaying information from her physicians and stating that she doesn't want you to give it. Patients relay information all the time from their physicians that I don't agree with. Doesn't mean I do what their physicians say. That's not fair to the patient or myself.

If I may, in this particular situation, the problem came up because I relayed the info (and bleeding tendency is in the chart) but there was no follow-up (with surgeon or GI/hematologist etc.) to at least confirm what was said about NSAIDs.

For example, I also told him I have anaphylaxis to a particular antibiotic and named the one I usually get - he confirmed with surgeon and administered it.

 

[gotname]

Patients say all kinds of crazy things. I step lightly around crazy people, and of course wouldn't give a crazy person a drug he thinks he's allergic too.

I think sometimes as patients we do mistake severe side effects for allergies...I did when I was a teen then my doctors corrected me.

But a few years back, I had an anaesthesiologist insist I could not be allergic to zofran. He really thought I was crazy. Gave it to me anyway. Anaphylaxis.

 

[pgg]

gotname, I have to ask ...

Are you a student, or a doctor? It appears everything you've ever posted on SDN has been about your experiences as a patient. Usually when people do that, they're asking for medical advice, but you're not. Are you a tourist?

 

[Ignatius J]

You will become less idealistic when you start working under your own license

I do work with my own license.

 

[Ignatius J]

If I may, in this particular situation, the problem came up because I relayed the info (and bleeding tendency is in the chart) but there was no follow-up (with surgeon or GI/hematologist etc.) to at least confirm what was said about NSAIDs.

For example, I also told him I have anaphylaxis to a particular antibiotic and named the one I usually get - he confirmed with surgeon and administered it.

1.) A patient with known thrombocytopenia does not require confirmation with a hematologist as to NSAID usage. That is well within an anesthesiologist's scope of knowledge. Quite frankly, if you're saying you teeter totter between coagulopathic and not and were brought back for a hemorrhage then that is on your surgeon and is laughable if he blamed anesthesia on that one for administering a single dose of Toradol.

2.) Again, a single dose of Toradol has been shown to have almost zero effect on bleeding.

3.) The antibiotic situation requires clarification. What is your allergy? What and when did he administer it?

 

[gotname]

gotname, I have to ask ...

Are you a student, or a doctor? It appears everything you've ever posted on SDN has been about your experiences as a patient. Usually when people do that, they're asking for medical advice, but you're not. Are you a tourist?

Just a patient and not a tourist...I did want to go into medicine but my health got the better of me blah blah .

My docs keep me interested and educated about everything medical so after I found this site by accident, I usually just read stuff once in a while. As you can see, never post much. I don't have a need for advice (got my docs & it is against SDN rules) but I like seeing where you all stand on various things.

 

[pgg]

Fair enough, welcome.

 

[gotname]

1.) A patient with known thrombocytopenia does not require confirmation with a hematologist as to NSAID usage. That is well within an anesthesiologist's scope of knowledge. Quite frankly, if you're saying you teeter totter between coagulopathic and not and were brought back for a hemorrhage then that is on your surgeon and is laughable if he blamed anesthesia on that one for administering a single dose of Toradol.

2.) Again, a single dose of Toradol has been shown to have almost zero effect on bleeding.

3.) The antibiotic situation requires clarification. What is your allergy? What and when did he administer it?

1. I have ITP. I was saying that the issue was that he confirmed the antibiotic info I gave but not the NSAID. I hope you realize I am telling you why the surgeon was upset, not me.

2. Yes, I understand that and I don't dispute it.

3. I am allergic to vancomycin. Anaphylaxis. He confirmed my story with surgeon then he administered something else (this was started prior to going into OR).

 

[gotname]

Fair enough, welcome.

Thank you.

 

[Ignatius J]

1. I have ITP. I was saying that the issue was that he confirmed the antibiotic info I gave but not the NSAID. I hope you realize I am telling you why the surgeon was upset, not me.

2. Yes, I understand that and I don't dispute it.

3. I am allergic to vancomycin. Anaphylaxis. He confirmed my story with surgeon then he administered something else (this was started prior to going into OR).

Fair enough. I think your surgeon should be made keenly aware that the cause of post-operative hemorrhage was most likely your ITP, and blaming it on Toradol suggests a level of denial. I don't know your surgeon and perhaps he was very cordial about it, but it is borderline incompetent to have a patient with ITP undergo surgery and a subsequent hemorrhage and then blame it all on a single dose of a medication that has been shown to not affect surgical bleeding.

 

[leaverus]

Fair enough. I think your surgeon should be made keenly aware that the cause of post-operative hemorrhage was most likely your ITP, and blaming it on Toradol suggests a level of denial. I don't know your surgeon and perhaps he was very cordial about it, but it is borderline incompetent to have a patient with ITP undergo surgery and a subsequent hemorrhage and then blame it all on a single dose of a medication that has been shown to not affect surgical bleeding.

while i agree with you that the ketorolac is very unlikely the culprit i also think the anesthesiologist brought the blame on himself. having the information given to him during the pre-op and still saying one dose won't hurt is a bit silly i think (though i agree); it was pretty much the patient saying "dont give me such and such drug" and he chose to give it anyway. like others have already said, sometimes it's better to just do things the way the patient says (directly or indirectly)

 

[Ignatius J]

while i agree with you that the ketorolac is very unlikely the culprit i also think the anesthesiologist brought the blame on himself. having the information given to him during the pre-op and still saying one dose won't hurt is a bit silly i think (though i agree); it was pretty much the patient saying "dont give me such and such drug" and he chose to give it anyway. like others have already said, sometimes it's better to just do things the way the patient says (directly or indirectly)

Yeah, whether the anesthesiologist brought blame on himself is a good debate. However, I do take serious issue with this surgeon taking a thrombocytopenic patient back with ITP and blaming subsequent bleeding on Toradol. That's incompetence. And a competent one would not deflect the blame away from himself like that. It was said that the surgeon knew the patient well and his/her history. Apparently, he didn't.

 

[DavesNotHere]

I've seen the evidence that toradol doesn't increase post-operative incidents associated with bleeding...but it does increase bleeding time...so that would increase bleeding intra-op and make it more difficult for the surgeon correct?

I'm asking for my own education. Thanks.

 

[Shouldawouldacouldas]

No one (lawyers) cares if there is no evidence that toradol doesn't increase postop bleeding. Toradol has a BLACK BOX WARNING about bleeding. Go to your hospital pharmacy and ask for the insert label. My stand is to never give toradol. My CRNA's, if they give toradol, must document that the surgeon requested or approved it. There are better ways to treat pain. The only time I use toradol is when the pt is a recovering addict and there is a possibility of covering postop pain with APAP and Toradol. If there is no chance of pain control with those two, then unfortunately the pt may need to go through rehab again.